Note : Les descriptions sont présentées dans la langue officielle dans laquelle elles ont été soumises.
:l~Z63~03
This invention relates to a neph-rologico-urological
medication which is particularly suitable for cornbating phos-
phatic calculi.
In the course of epidemiological studies in recent years,
S it has been shown that an average of 4% of the adult population
sl~ffer from urinary calculi one or more times during their lives
Urinary calculi are borderline cases of bio-minerali~ation.
They have a multi-casual origin determined by patholigico-anatom-
ical, metabolic and physico-chemical factors. The composition of
urinary calculi also determines why they are formed. It is
possible to carry out an accurate quantitative analysis of
urinary calculi by chemico-physical investigation methods such
as infra-red spectroscopy and X-ray diffraction.
The majority of urinary calculi, about 15 to 20%, consist
o differen~ phosphates. A list of the phosphates more commonly
found in urinary calculi is given below:
CHEMICAL NAME FORMULA MINERALOGICAL
NAME
-
Calciumhydrogenphosphate CaHPO4.2H20 Brushite
Tri-Calciumphosphate Ca3(P04)2 Whitlockite
Hydroxycalciumphosphate Cal0~po4)6~oH)2 Hydroxyl-Apatite
Carbonateapatite Calo(po4co3oH)6(oH)2 Dahllite
Magnesium-~nmonium- iMgNH4PO4.6H20 Struvite
phosphate
-- 1 --
~Z~i~6~3;3
A dec:isive factor in phosphatic-calculus forination is the
p~l value of the urine '~'he over~helrll:ing majority of phosphatic
calculi occur in an alkcl1ine environmerlt. rl'hlls, apatite, carbon-
ate-apatite and struvite crystallize at urine-pH values above
7.0 "~hereas brushite crystallizes at urine-pH values of 6.8 to
7Ø
There are vàrious reasons for the formation of phosphatic
urinary calculi. ~or example there are urinary infections with
urease producing germs which alkalize the urine by urea fermen-
tation; this produces supersaturation of magnesium ammonium-
phosphateJ calcium-phosphate and monoammonium urate in the urine~
followed by crystallization and subsequent formation of the above
mentioned urinary calculi: struvite, carbona~e-apatite and mono-
ammonium urate. This is usually accompanied by factors w'hich en-
courage this formation, for instance an inadequate amount of urine,
a lack of citrate or inhibitors, and excessive concentrations of
calcium and phosphate in the urine.
Another of the many reasons for the formation of calcium
phosphate concretions is dysbolism, for example renal tubular
acidosis which also leads to an increase in the pH value of the
urine; the incomplete form of renal tubular acidosis may be com-
pensated for by acidifying the urine.
Moreover, in addition to the change in calcium and phosphate
separation, for example under conditions of primary hyperpara-
thyroidism, the pH value of the urine is a factor which encourages
,
~ `
.
~;3~3
the formation of phosphatic calculi Accordingly a lowering of
the pll va]ue may also be nee~ied.
The therapeutical objective, in the case of phosph<lte-calculus
diathesis ie acidification of the urine, should also be carried out
with a minimum of metabolic stress. Preference should therefore
be given to medications which produce a substantial acidifying
effect with a small dose.
Up to now, L-methionine, NH4Cl, acidol pepsin and ascorbic
acid have been used, as urine acidifying preparations, in combating
phosphatic calculi. Some of these medications must be administered
in very large daily doses if adequate acidification of the urine
is to be achieved. However, this high intake also sùbjects the
organism to considerable metabolic stress; this applies in particular
to the metabolism of the liver and may lead to changes in blood and
liver values.
The present invention seeks to provide a preparation which
will acidify the urine and which can be administered in adequate
amounts without stressing the organism, especially the metabolism
of the liver.
~o In accordance with the invention the nephorologico-urological
agent, developed to this end contains L-cysteine and/or a pharm-
acologically compatible acid addition salt of L-cysteine.
Preference is given to units of administration containing
0.75 g of L-cysteine monohydrate monohydrochloride. As compared
; 25 with the known L-methionine, of which 3 g/diem are administered
,
W~33
in orcler to .lcidify the orine (corresponding to 40.2 mmoles of
H+~, 2.35 g/diern of L-cysteine HCl.H20 produce the same effect.
The following Table I shows the amount of L-cysteine IICl.ll20 and
methionine required for corresponding acidification.
Table I
____
n~lol H+ L-Cysteine-HCl.H20 L-Methionine/diem
.
1.464 g 1.865 g
2.049 g 2.611 g
2.342 g 2.984 g
4~ 2.810 g 3.581 g
It will be seen that the necessary doses of L-methionine are
distinctly larger.
The L-methionine compound also used to acidify urine possesses
an -SCH3 group instead of an -SH group as in the case of L-cysteine.
- During metabolism, therefore, the two compounds go in different
directions. The necessary demethylation of the L-methionine,
before _S is oxidized to SO4 in the ~ody, causes stress in the
organism and produces intermediate products.
L-cysteine HS-CH2-CH(NH2)-C00~1
L-methionine CH3S-CH2-CH2-CH(NH2~-COOH
Tnstead o cysteine hydrochloride it is, of course, possible
; - 4 -
:
to provide other aci(l addition sa]ts of L-cysteine itself which is
then converted to cysteine hy(lrochloride in the stomach. However,
L-cysteine-hydrochloride is preferrc~ for H~ -ba]ancin& reasvns
In the course of various series of tests) groups, each con-
S sisting of 6 healthy male testees, having ~m average bodily weight
of 75 kg and aged between 25 and 30 years, were treated as follows:
The testees were given a normal, roughly standardized, mixed
diet. After a monitoring period of 4 days, the following amounts
of acid suppliers were administered to the testees daily, over a
period of 14 days:
Group A: 3 x 2 tablets of an aci' mi~ ure (one tablet :
150 mg of NH4Cl, 100 mg of lysine HCl, 100 mg
of betaine HCl)
Group B: 3 x 4 tablets of an acid mixture (s. a.) cor-
responding to 48 mmols of H+ ions;
Group C: 2~4 g. of cysteine HCI.H20 corresponding to 41
mmols of H~ ions and 13.7 mmols of sulphate.
Before lunch, 22 ml of whole blood were taken from the testees.
This was done daily during the monitoring period and on the 2nd,
4th, 8th, 11th and 14th days during the test peTiod 2 ml of this
blood were mixed with heparin for blood gas analysis. The re-
maining 20 ml of blood were usedl without additives, as a centri-
fuged serum, for the determination of sodium, potassium, chloride,
calcium, inorganic phosphate, parathormone, 25-OH vitamin D3,
ammonia, creatinine, uric acid, sulphate, magnesium, r-GT and
,
citrate.
Throughout the test period, 24 hour urine was collected and
refrigerated, with 5 ml of isopropanol as a prcse-rving additive.
The collecting period ran from 7.00 each morning to 7.00 on the
S following morning.
The 24 hour urine was tested for volume, specific weight, pH
value, ammonia, titration acidity, total acidity, pC02, potassium,
sodium, chloride, calcium, inorganic phosphate, magnesium, sulphate,
creatinine, uric acid, oxalate, citrate and cyclic AMP.
The following Tables II tolIV show results obtained with
cysteine HCl, together with data rom a subsequent check
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_ 9 _
~36~3
The data repro(luced in the Tables provide the fol~o~ing
picture:
Daily aclministratioll of acid in the forrn of 41 mmols of
cysteine IIC~ (about 13.7 nmlols Cl ~ S) leads to urine acidosis
with increased separation of sulphate, with only a te~nporary
increase in calcium conversion and no increase in parathormone
secretion.
Acid-base conversion:
During administration of the acid, the pH value of the
urine drops, on an average, by 0.64 pH units to pH 5.61.
Total acidity of the urine (NH4 l tit. acid. - HC03~ in-
creases, on an average, by 51.9 mmols/d from 60.1 to 112.0 mmols/d;
titration-acidity increases by 18.1 mmols/d and ammonia separation
by 32.0 mmols/d, while bicarbonate separation decreases by 4.1
to 0.6 mnlols/d. Three days after the therapy has been discon-
tinued, total acid separation has still not reverted to the original
values, although sulphate separation becomes normal after 24 hours.
In the blood~~however, the pH value drops only glightly, in
the first week, by 0.05 pH units to pH 7.30, in the second week
it is bac~ to its original value. Standard bicarbonate (about 23.2
mmols/l) and PC02 (about 6.7 kPa) remain unchanged in the normal
` range as do serum ammonia values. Thus no tendency towards meta-
bolic acidosis is found in the blood.
Electrolyte conversion:
Sodium and potassium va]ues in the serum, and sodium and
- 10 -
potassium se~aration in the llrine, reloain unchanged wherl cysteine
I~Cl is used. Upon tcrminlltion of the cysteine therapy, potassium
separatioll val~Jes dlclirle by l0 mrnols/d.
A on conversion:
Chlorine separation in the urine amounts to 24 mrnols/d and is
thus greater than is to be expected from the additional supply of
13.6 mmols/d. It remains high evcn during the three day subsequent
check. Unchanged normal chloride values are found in the serum at
all times.
With the use of cysteine ~ICl, sulphate separation in the urine
increases, on an average by 13.9 mmols/d, and this also agrees with
the additional supply of sulphur. Serum sulphate values increase
slightly from 175 to 216 umols/l.
Bicarbonate separation increases, on an average, by 3.5 mmols/d
during the acidification.
Phosphate separation increases by 5.5 mmolstd only during the
first week of cysteine administration. Because of the reduction in
the valency of the phosphate ion in the acid, this signifies, on an
average over the two weeks, an increase of about 2 mmols/d in anion
valences. No phosphate changes occur in the serum.
Citrate separation decreases from 2.81 to 1.82, corresponding
to a reduction in anion valences of about 2 mmols/d with decreasing
pH values. The citrate values also remain low for three days after
the cysteiile is discontinued.
There is no change in uric acid and oxalate separation under
~2~36~
cysteine ~ICI ther~lpy, nor in Se~Uln U*iC acid VallleS.
Ovcrall, with the adrn;rlistrcltion of 41 mmols/d of acid and
cysteine ~ICl ther.lpy, an ~Idditior~ 8.5 mmols/d of arlion valances
are separated renally, as compared with ~m additional cation
separation of about 34 mmols/d (32 mmols of Nl-l~, 2 ~nols of Ca ~.
Mineral conversion and regulators:
After administration of cysteine HCl, calcium separation with
urine increases, only during the first week of the medication, by
2.51 mmols/d, from 4.68 to 7.19 mmols/d. After the fifth day, and
during the second week, calcium separation decreases to the original
values. When considered over 14 days, therefore, these values do
not really change. In the serum, there are also no changes in
calcium level.
Cysteine HCl therapy increases magnesium separation slightly
by 0.47 mmols/d.
In contrast to NH~Cl acidosis, the level of parathormone in
the serum has a tendency to decrease under cysteine HCl. The values
found are 39 ng/l lower than would be expected from the initial
value of 428 ng/l.
25-OH vitamin D3 in the serum is reduced slightly, only in
the first week of the therapy, by 7 nmols/l; in the second weeU
it returns to the initial values. Thus, on an average, no definite
changes are to be observed over the entire period.
cAMP separation in the urine is not affected by cysteine HCl.
Values are around 5.2 ,umols/d.
:
.
- 12 _
~ '
~L2636(~3
Kidney and liver fllnction:
_ ~
Urine volume and specific we;ght rerrlain constant throughout
the test period.
~ There ls a slight ;ncrease of about 1.0 mmo~/d in creatinine
S separation during the adrninistration of acid; thus serum creatinine
is unchanged while creatinine clearance increases by 15 ml/min to
143 ml/min.
Throughout the test period, r -GT in the serum rernains at about
lO U/l. Under cysteine HCl> the acidosis represents a combined
sulphate HCl acidosis because the S}l groups of the cysteine are
oxidized in the body cells, by cysteic acid, to sulphate. The amount
of chlorine supplied is not fully separated renally in the case of
NH4 acidosis, but renal separation is complete with sulphate HCl
acidosis. In the serum, therefore, the sulphate level increases
~15 slightly.
The following Tables V and VI show results with different
amounts of acid.
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It will be seen ti~c1t ~hen ~oscs of mi-~ed aeids are adrnir1is-
tered, correspondiJ1g to 2~ and ~8 mlllols H /d ac;d mi~tllre (one
tablet: 150 mg of N~14C,l, l00 Ing of lysine 11(:1, 100 mg o betair1e
HCl) which are less tilan those frc(iuently 11sed, c1efinite ;ncreases
are observed after a brief decrease in parathormonc values in the
serum, but with larger doses this occurs àftcr some delay. Finally,
hyperphosphaturia and hypercalciuria correlate with these increases,
although a trend towards a decrease in calcium and an increase in
phosphate i~ perceived in the serum. The decline of 25-OH-vitamin
D3 in the serum is also to be interpreted as an indication of
hyperparathyroidal metabolic condition because parathormone
activates 25-OH-lc~-hydroxylase in the kidney, so that 25-OH-
vitamin D3 must decrease. The decrease in 25-OH-vitamin D3 also
clearly correlates with a phosphaturic tendency. The inverse
calcium phosphate mo-vement in the serum constitutes an additional
incentive to parathormone secretion, which appears to be more
effective in the case of a metabolic acidotic metabolic condition.
The apparent increase in the formation of l.25-(OH)2-vitamin-D3
activates calcium and phosphate absorption in the intestine and,
together with parathormone, bone resorption. Thus calcium and
phosphate losses occurring renally under acidosis, which initially
lead to a slight decrease in serum calcium, are compensated for in
such a manner that even a slight increase in phosphate is obtained
in the serum.
With the larger administration of acid, in the form of 48 mmols
- 19 -
~Z~3~3
H -ions/d, there is no compcnscltion for loss of calcium from the
serum because the clistinct increase in parathormone also takes
place only at the end of the second week of the therapy.
On the other hand, under cystelnc IICl a~lTrlinistratiorl of 41
mmols }I -ions/d, corresponding to sulphate ~ICl acidosis, there
is no increase in parathormone secretion and no changè in calcium
and phosphate values in the serum throughout the entire duration of
the test, although urine acidosis is visible and serum sulphate
values are also slightly higher. At the same time, however,
calcium and phosphate mobilization in the urine is weaker and
there is no excessive separation of c~MP to be observed in the
urine. It is only during the first week of administration of
cysteine that a slight drop in 25-OH-vitamin-D3 values in the
serum is to be observed, combined with a temporary increase in
calcium and phosphate separation in the urine. In spite of a
slight increase in serum sulphate values, after a few days of the
treatment with 41 mmols H ions/d, there is no longer any change
in blood-gas-analysis values and other parameters of mineral
metabolism to be recognized, although the full effect of acidosis
is apparent in the urine. Here again, however, the increase in
calcium and phosphate separation takes place only at the beginning
of the therapy, over a period of about 5 days.
All i~TI all it may be stated that the use of cysteine in
acid therapy produces far fewer side effects than that the hitherto
usual NH4Cl or the L-methionine dose. L-cysteine is also administered
'
3~03
in rnl~ch sma11er doses.
The adlninistra~ion of 1() mmols of acid va]cnce produces a
change in urine pll of 0.15 pl-l urlits. Bascd upon this, the amollrlts
to be administered should be such that the urine pll de~finitely
remains under 6.0 but is not less than 5Ø This means daily
doses of cysteine HCl of 2.25 g in the form of three 750 Mg
tablets.
L-cysteine has been used in therapy for many years as a liver
preparation. Preparations with 250 mg/tablet are known for daily
doses of up to 1 g. There are numerous works from that time re-
lating to protection of the liver, among other things, dealing
with the preventive and curative, necrosis avoiding effect.
The fact that L-cysteine HCl.H20 has specially favourable
properties for the acidification of urine has hitherto not been
recognized.
The L-cysteine or its pharmacologically acceptable acid
addition salt is suitably administered in admixture with a
pharmaceutically acceptable carrier which may, for example be a
sold carrier; *he mixture being tableted, or a liquid carrier.
It will be understood that the active ingredient is employed
in admixture in an amount to provide a nephrologico-urologically
effective amolmt.
~ The pharmaceutical composition comprising the admixture of
L-cystem e or its pharmacologically acceptable acid addition salt
and carriel may contain other conventional additives and excipients
- 21 -
` ,~
i3~(~3
for pharmaceutic~l c01l)positiorl. Such compositions are produced
employing conventional MiXing teChrliqUes.
The pharmacologically cornpat;ble acid ad(3ition salts may be
produced in Icnown ~nner by reacting the L-cysteine with a suit-
able organic or inorganic acid. It will be understood that the
acid should be non-toxic at least in the amounts in which it is
introduced into the body and should be physiologically or pharm-
acologically compatible.
, :
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, ~
~ .
